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Table 2 Summary of the eight original studies investigating the effect of using the Liverpool Care Pathway (LCP) in nursing homes (NH)

From: The Liverpool Care Pathway: discarded in cancer patients but good enough for dying nursing home patients? A systematic review

1st author, year, nationality, Grading Design/participants Study objective Outcome measures Results
Watson J, 2006 [12], UK Mixed method: qualitative and quantitative data were collected in 8 NH before, during and after the implementation of the LCP related to a 5-year action research project (Bridges Initiative) to develop practice around high quality end-of-life care in NHs Explore barriers during implementing an integrated care pathway
for the last days of life in nursing homes
- Documentary analysis of notes
- Group interviews with trained staff, care assistants, GPs, relatives
- Field notes
- Participant observation
Six barriers through lack of:
1. palliative care knowledge, drugs and symptom control
preparation for imminent death
2. knowing the dying process
multidisciplinary team in NH
3. confidence in communicating
readiness/ability to change
Grading: 2b
Veerbeek L, 2008a [17, 18], The Netherlands Non-controlled, pre- and post-intervention design in hospitals, NHs, at home: In the baseline period (11/2003–02/2005) 219 nurses participated for 220 deceased patients (n = 102 from NHs). In LCP intervention period (02/2005–02/2006) 253 nurses for 255 deceased patients (n = 114 from NHs). Investigate effect of LCP on documentation of care, symptom burden and communication Gender, age diagnoses
After death of the patient, a nurse filled in the EORTC QlQ-C30 and VOICES, within 1 week after death. Relatives received the questionnaires 3 months after death.
LCP was used for 197 of the 255 dying patients (77%). Compared to baseline, the intervention had better documentation of care and lower symptom burden. The LCP implementation and use, pain and symptoms in NHs and persons with dementia were not reported, specifically. Study was not blinded.
Grading: 2b
Veerbeek L, 2008b [17, 18], The Netherlands Non-controlled, pre- and post-intervention design in hospitals, NHs, at home: In the baseline period (11/2003–02/2005) relatives participated for 56 NH patients. In LCP intervention period (02/2005–02/2006) relatives participated for 58 NH patients. Investigate whether use of LCP affects relatives’ retrospective (4 months after death) evaluation of communication and level of bereavement Views of Informal Carers—Evaluation of Services question-naire (VOICES) Communication and end-of-life care were equally positively evaluated in both periods in the NH. In LCP group more relatives found information comprehensible, but difference was no longer significant after adjusting for differences in patient and relative characteristics.
Grading: 2b
Van der Heide A, 2010 [19], The Netherlands Non-controlled, pre- and post-intervention design in hospitals, NHs, at home. Patients with cancer; 83 patients with cancer died in the NHs. Data collection from physicians 1 week after death; from relatives 2 month after death Retrospective evaluation of end-of-life decision-making practices for cancer patients who died in each of these settings and assessed the impact of LCP C30 for physicians and relatives 80 physicians and 51 relatives filled in C30. Patients were included regardless the use of LCP (n = 40 used LCP in the NH). LCP had no significant impact on general drugs use during the last 3 days of life. Physicians estimated that drugs shortened life in 33% of NH patients. Parenteral sedation was used in 33% of NH patients. LCP reduced life-shortening drugs but it is not clear in what type of setting.
Grading: 3b
Clark JB, 2012 [20], New Zealand Mixed method: questionnaire sent to 194 health personnel from three NHs, 12–18 months after implementing LCP. 26 respondents. Qualitative interviews, both one-on-one (w/ one nurse, three physicians, one manager) and focus group (15 participants). Investigate health personnel’s experience of LCP used in dying patients - non-validated questionnaire (10 sider, 55 questions)
- interviews
26 responders (13% response rate); 12/55 were reported: LCP-use positively evaluated in terms of communication, documentation, symptoms management, and education. The implementation of LCP was not described.
Grading: 4
Lokker ME, 2012 [21], The Netherlands Retrospective survey (2 months after death) including relatives/health personnel of persons who died in a hospital (117), NH (67), own home (82). Persons with reduced cognitive capacity were excluded, 70% cancer. LCP implemented midway through the study period (11/2003–02/2006) Investigate if LCP use has an effect on how well the patients understand their terminal condition and dying as imminent. 28 symptoms from the EORTC QLQ-C30 LCP used in 33% of participants. The comprehension of dying as imminent was not related to LCP, age or diagnosis. LCP use, pain and symptoms in NHs and persons with dementia were not reported. Implementation of LCP was not described.
Grading: 2b
Brannstrom M, 2015 [22], Sweden Retrospective controlled survey (1 month), including relatives/health personnel of persons who died in 19 NHs (intervention n = 71, control n = 64) in one Swedish municipality (06/2009–10/2011). 3-h LCP education. Investigate the effect of LCP on pain, symptoms and QoL in the end of life, before/after implementation -ESAS
Dyspnea and nausea was better treated in the LCP treated group (evaluated by VICES and ESAS respectively). Other symptoms were not mentioned.
Grading: 2b
Raijmakers N, 2015 [23], The Netherlands Qualitative study including LCP managers from 10 organizations (four hospices/palliative NH units, three hospitals and three home care services Identify barriers and promotors for the implementation of LCP Telephone interviews and focus groups Barriers/promotors for implementation of LCP in NHs/persons with dementia were not specified in results/discussion.
Grading: 4
  1. C30 = Cancer Quality of Questionnaire (for relatives and physicians); DNAR Do Not Attempt Resuscitation, ESAS Edmonton Symptom Assessment System, PCU = Palliative Care Unit, VOICES Views of Informal Carers - Evaluation of Services; EORTC QLQ-C30 = A core quality of life questionnaire covering general aspects of health-related quality of life and disease- or treatment-specific questionnaire modules